Hydration

Assessing hydration in a patient

A popular OSCE question. Which makes it surprising that it's always such a surprise, maybe because - Surprise! - we've never been taught it.

Situations where assessing the fluid status is important eg dehydration:-
-Vomiting
-Sepsis
-Bowel obstruction
-Bleeding
-Recent Surgery
-Diarrhoea
-Fever

Causes of fluid overload:-
-Right heart failure
-Constrictive pericarditis
-Hypoalbuminaemia

Anyhoo - how to assess someone's hydration status, whether dehydrated or fluid overloaded:

General Inspection
I'm looking at the environment to see if there are any important clues into the patient's fluid status. This includes
-fluid restriction,
-drugs
-drips
-lines
-catheter bags,
-or nutritional supplements.

I am then looking at the patient to see if there is any obvious signs of them being
-dehydrated
-or fluid overloaded, e.g. oedema.

Hands
Starting with the hands I am
-feeling them
-and testing the capillary refill to see if there are signs of peripheral shutdown.
Dehydration would be indicated if the cap refill was prolonged.
Normal <2s.

Wrist
I am palpating the
-pulse.
Both dehydration and fluid overload would cause a tachycardic pulse.

Arm
I am testing
-the blood pressure,
-both sitting and standing.
If there was a decrease in the pressures this could indicate dehydration.

Wait 3 minutes between sitting and standing.
Fall in >20mmHg Systolic or >10mmHg Diastolic = Postural Hypotension

Neck
I am looking at the patient's neck to assess
-the JVP, as its height is an indicator of intravascular volume.
Normal = 2cm above sternal angle

If it is diminished, this indicates dehydration.
If it is raised it can indicate fluid overload.

Face
I am looking at
-the eyes, to see if there are sunken orbits. This can indicate moderate to severe dehydration.
I am also looking in
-the mouth to see if there is a lack of moisture, which indicates dehydration.

Chest
Looking at the chest, I am assessing
-the skin turgor by pinching a fold of skin at the sternum (this could also be done on the forearm) for a few moments and then releasing it.

If the skin resumes its place quickly the skin turgor is normal, but if takes a longer amount of time the skin turgor is reduced, and this indicates dehydration.
NB This test, however, is of less use in the elderly when there is loss of skin elasticity.

Oedema
I am checking
-the sacral region
-and legs for signs of oedema, and therefore fluid overload.

Auscultation
I am listening to
-the lungs for the presence of fine inspiratory basal crackles, which could indicate pulmonary oedema
-additional heart sounds to indicate a hyperdynamic state

And to finish off...
I'd like to check the patient's
-temperature
- obs chart (temperature, BP, O2 sats, pulse, RR)
-urine output/catheterise
- fluid balance chart
Inputs (IV fluids, oral intake)
Outputs (urine, stool, drains, stoma bags etc) - vomiting? diarrhoea?
- drug chart – is patient on any diuretics?
- notes - recent surgery?
- further Ix i.e. U&Es, FBC, central line monitoring

Pancreatitis

Pancreatitis

Your friend and mine... actually scratch that, pancreatits is pretty sucky as diseases go, mainly because the pancreas is not encased in a protective lining like other organs are.

Consequently, when it gets damaged and starts releasing its digestive enzymes it has no where to go but on itself - leading to a sort of auto-digestion, and the surrounding organs - ew. This creates all sorts of inflammation. As I said, pretty sucky. Plus, ma-hoo-sive 3rd space losses means gallons of extracellular fluids get trapped in the gut, peritoneum and retroperitoneum (meaning 'behind the peritoneum', from the original Greek - peritoni-, meaning 'lining', and retro- 'meaning from the 70s' - due to the tiny disco ball found lying behind there*). The body decompensates rapidly in this condition, and so the patient, as a result, becomes very unpredictable - able to be chatting one minute, and in severe shock the next.

There are several kinds:
Acute
Chronic
Obstructive
(due to obstruction of the pancreatic duct, but basically shares features with the acute and chronic forms)

Acute Pancreatitis

10-20/100 000 West society

*mild/self-limiting

1/5 - severe = shock/organ failure/death

Symptoms

Central/epigastric pain radiating to the back. +/- nausea, vomiting. Possibly relieved on sitting forwards.
Tachycardia

Causes
Using the infamous GET SMASHED

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune (PAN)
Scorpion Sting (Trinidadian)
Hyperlipidaemia/Hypercalcaemia/Hypothermia
ERCP
Drugs

plus Pregnancy and Idiopathic, Infections, Ischaemia

Gallstones & Chronic alcoholism = 70%
Idiopathic = 20%

Poor ol', IDIOtic Amy, she got SMASHED, & woke up PREGNANT. You'd think she's have more sense.

Pathogenesis

Enzymatic auto-digestion of pancreas

Acinar cell damage = release of pro-enzymes into interstitium, where activated

Mechanisms

 - Direct - Trauma/infection/alcohol

 - Oxidative stress

 - Acinar cell ischaemia (retained pancreatic secretion, inflammation, oedema, vascular constriction)

leading to...

Acute inflammation

Microvascular leakage

Oedema

Fat necrosis

Proteolysis

Vascular destruction

Haemorrhage

Ix
Increased WCC

Increased plasma pancreatic enzyme levels x3 (within 24 hours)
RANSON criteria indicates clinical outcome

Glasgow Criteria for assessing severity of pancreatitis
(NB only validated for gallstones & ethanol as the cause)

PANCREAS

PaO2 <8kPA

Age >55yrs

Neutrophils WBC >15x10

Calcium <2mmol/L

Renal function Urea >16mmol/L

Enzymes LDH >600iu/L & AST>200iu/L

Albumin >32g/L

Sugar BM>10mmol/L

3/3+ positives within 48hrs = severe pancreatitis. Transfer to ITU/HDU.

Pathology
Mild

Interstitial oedema

Focal fat necrosis

Pancreas swollen

Superficial white plaques of fat necrosis (fatty acids + Ca)

Severe

Necrotizing
Affects acini, ducts, islets

= w/spread necrosis and Hg

Macro

Yellow/white chalky fat necrosis, with areas of black haemorrhage

Peritoneum = brown, serous fluid - fat globules & chalky deposits
Micro

Interstitial oedema
Peri-pancreatic fat necrosis

Severe
Extending necrosis

Acini and blood vessels destruction
With septal acute inflammation cell reaction and haemorrhage

Tx

Mild episode & majority of cases
Resolve with supportive treatment
Min organ dysfunction

Course and Cx

Severe episode

Pancreatic necrosis (Dx at CT)

Local damage

Pancreatic abscesses

Pancreatic pseudocysts

Duodenal obstruction

Path = complete resolution/focal fibrosis

Multi-organ failure

DIC

ARDS
Death - 30% in severe acute pancreatitis
Early deaths = organ failure

Late deaths = infection

5% mortality = shock w/i 1 week of perforation

*Total BS

Causes of Haemolytic Anaemia

SHEEP TIT

ew, but there you go

Sickle cell disease
Hereditary spherocytosis
Enzyme deficiencies (G6PD, pyruvate kinase)
Erythroblastosis fetalis
Paroxysmal nocturnal haemoglobinuria

Trauma to RBCs (mechanical heart valves, DIC, cardiac haemolysis)
Immunohaemolytics (warm Ab, cold Ag, drug induced, transfusion reaction)
Thalassaemias

or TASTE the PuB DISH

Thalassaemia
Autoimmune (warm Ab, cold Ag, drug induced, transfusion reaction, haemolytic disease of the newborn)
Sickling disorders
Trauma to RBCs (mechanical heart valve, cardiac haemolysis, MAHA)
Enzyme deficiencies (G6PD, pyruvate kinase)

the

Paroxysmal nocturnal haemoglobinuria
u
Burns

DIC
Infection (malaria, septicaemia)
Spherocytosis
Hypersplenism

with help from:
http://www.scribd.com/MemorableMedicine

... I really hope that this is relevant...

Otherwise I'd feel like a bit of a tit, making all this effort.
Or a sheep tit, if you will.

Causes of Anaemia

Causes of Microcytic Hypochromic Anaemia

TICS - "Tiny Tics cause Microcytic Anaemia"

Thalassaemia
Iron deficiency
Chronic disease
Sideroblastic anaemia

or "Find Those Small Cells" * - I think this is my favourite

Find = Fe deficiency
Those = Thalassaemia
Small = Sideroblastic anaemia
Cells = Chronic disease.

or "Heavy Sid 's Always after Tha Lasses"

Heavy = Fe = Iron Deficiency
Sid's = Sideroblastic Anaemia
Always = Chronic Disease
Tha Lasses = Thalassaemia


Causes of Normocytic Normochromic Anaemia

ABCD

Acute blood loss
Bone marrow failure/infiltration
Chronic disease
Destruction (haemolytic) anaemia

'nuff said


Causes of Macrocytic Anaemia

"Macdonald's do FAB burgers"

Folate deficiency

Alcohol abuse
B12 (thiamine) deficiency

or

"FAT RBC"

Foetus (pregnancy)
Alcohol
Thyroid (hypo)

Reticulocytosis
B12/Folate
Cirrhosis

or

"FAT RBCs make me MAD"

Foetus (pregnancy)
Alcohol
Thyroid (hypo)

Reticulocytosis
B12/Folate
Cirrhosis

Multiple Myeloma/Myeloproliferative Disorders/Myelodysplasia
Aplastic Anaemia
Drugs (Methotrexate, Zidovudine)

and remember that both B12 and Folate are Megaloblastic, while the rest are Normoblastic.

with help from:
http://www.passmed.co.uk/anaemia.html
http://www.scribd.com/MemorableMedicine

Fractures #1

What is a Fracture?
A break in the continuity of the bone, which also results in damage to the surrounding soft tissue.

Types of fracture

Open fracture (compound) - where the surface wound communicates with the fracture itself, allowing for the possibility of contamination and infection.
Closed fracture - The skin or wound has an intact surface.
Intra-articular fracture
Extra-articular fracture
Displaced fracture
Undisplaced fracture

Transverse
Oblique
Spiral
Multifragmentary/Comminuted - >2 fragments
Avulsion - bony fragment torn off by tendon/ligament

Compression/Crush - crumpling of cancellous bone (calcaneum, vertebral)
Stress - repeated stress = bone fatigue
Greenstick - cortex has buckled on one side through bending rather than breaking, children
Pathological - fracture in a bone already weakened by disease. Through generalised bone disease (OP)/localised abnormality (mets)

OP fractures - *spine & femoral neck

Displacement of fractures
Impaction - fragments are driven into each other, causing shortening
Angulation/Alignment - fragments are in angle with each other. Describe in degrees & distal fragment,
Opposition - lateral displacement
Rotation - observed with mismatched widths of distal and proximal fragments.

Dislocation - complete loss of congruity between the articular surfaces of a joint.
Subluxation - partial loss of contact between two joint surfaces.

Fracture Healing

1) Bleeding into fracture
2) Inflammatory Reaction
3) Cell Proliferation, callus formed
4) Consolidation, lamellar bone
5) Remodelling under stress

Plastering
UL - 6 weeks
LL - 12 weeks

Cardiovascular Examination - The Script

WIPER

Washes hands.

Introduces self.
&
Asks Permission to examine the patient.

"Hi, my name is __________, I'm a final year medical student. Would it be alright for me to listen to your heart? Thank you."

Expose
&
Reposition

"I would like to have the patient at 45 degrees and exposed from the waist up. 
 Is it alright if I put you at 45 degrees? And are you fine to be undressed from the waist up? Thank you so much."

General Inspection


Bedside - 
"I'm looking around the bed for any 
- ECG leads,
- O2 therapy, 
- or medication, for example, GTN spray."

The Patient -
"I'm looking at the patient to see 
- if they look ill,
- are they SOB at rest,
- is there any cyanosis?
- Are they overweight or cachectic?
- Is there any obvious genetic syndrome, for example, Marfan's?"

Hands -
"Do you have any pain in your hands at all? May I have a look and feel of them?
I'm initially assessing for 
- the temperature 
- and hydration - are the hands particularly sweaty or clammy?
At the nails I'm testing 
- the cap refill 
- and looking for splinter haemorrhages.
At the sides of the fingers I'll inspect for
- signs of clubbing
- or tar staining.
I am then looking at the palms and finger pulps for 
- Janeway lesions 
- or Osler's nodes."

Wrist -
"At the patient's wrist 
- I'm feeling the radial pulse to assess its rate and rhythm."

Upper Arm  - 
"At the antecubital fossa 
- I'm palpating the brachial pulse, to assess rate, rhythm and character. 
- I would at this point also like to take the patient's blood pressure.
Do you have any pain in your arm or shoulder? If it's alright, I'm just going to pull your arm up, relax - it shouldn't hurt.
- I'm testing for the presence of a collapsing pulse."

Neck -
"I'm just to feel your neck now.
- At the neck I am palpating the carotid pulse to assess the rate, rhythm and character.
Can you look to your left, and rest your head against the pillow/my hand?
- I'm assessing the JVP to see if it's raised, and moves with respiration.

Eyes -
"Can you look at the ceiling for me? I'm just going to pull down your lower lid, if you don't mind.
I'm looking at the 
- sclera to assess for any sign of jaundice, 
- and I'm looking to see any paleness of the conjunctiva.
And look straight ahead now.
I'm looking at the 
- iris for corneal arcus.
- I am looking around eyes for xanthelasma."

Cheeks -
"I am looking at the cheeks for mitral facies."

Mouth -
"Can you open your mouth for me?
I am looking at 
- the lips for peripheral cyanosis
- I am looking at the soft palate
- and assessing the dentition.
Can you raise your tongue to the roof of your mouth?
I am looking 
- under the tongue for signs of central cyanosis.
You can relax your mouth now."

CHEST


Inspection - 
"I'm looking at the chest for 
- any scars, 
- pacemakers, 
- abnormal chest movements or shapes, 
- and whether there are any visible pulsations.
- I can also check their leg to see if I suspect vein graft surgery."

Palpation -
"Do you have pain in your chest? If it's fine I'm just going to have a feel of your chest. Can you lean to the left for me?
- I am palpating the apex beat.
- I am also palpating for the presence of heaves or thrills."

Auscultation -
"I'm just going to have a listen now - you can breathe normally.
- I am listening at the 4 areas, with both the bell and the diaphragm of the stethoscope.
Can you breathe in for me and hold your breath. Ok, thank you, now can you breathe out for me and hold your breath. Now breath normally. Can you sit up and lean forward for me? Can you lean towards you left-hand side for me?
If there is an abnormal sound I am assessing 
- the time, 
- the site and radiation (either at the carotids or the axilla), 
- the loudness and pitch, 
- and the relationship to respiration and posture.
Can you hold your breath for me?
- I am also listening at the carotids for any evidence of bruits.
You can breath normally now.
Can you lean forward for me?
- I am listening for evidence of basal crackles.
- I am also checking for sacral oedema.
Ok, you can lean back on the bed and relax. Thank you very much _______, I'm all done - do you need any help putting your clothes back on?

To finish off the exam I'd like to examine
- the peripheral pulses, 
- palpate the lower limbs for peripheral oedema,
- record an ECG, 
- do a urine dipstick
- and if relevant - check the legs for scars from vein grafts, and examine the abdomen, particularly the liver if I suspect right heart failure.
Thank you again."

The ''And finally..." can be remembered handily by
DOPE as in "the person who writes this blog is dope... and for some reason I'm using slang from the 90s."

Dipstick
Oedema
Peripheral Pulses
ECG

I thank you.
Take a bow. Take a bow.

Risk Factors - Thromboembolism

The major risk factors for DVT/PE can be remembered with the mnemonic

His Leg Might Fall Off

History of thromboembolism
Immobility (hospital/institution)
Surgery (*abdominal/pelvic/orthopaedic)
Varicose Veins in the Leg
Malignancy
Fracture/Trauma
Oestrogen (pregnancy - *late, OCP, HRT)

thanks to:
http://youngmongoose.blogspot.com/2010/02/dvtpe-risk-factors.html

Minor Risk Factors include:
CVS - MI/HT/Heart Failure/Indwelling Central Line
Resp - COPD
Haem - Thrombophilia eg antithrombin, Protein C or S deficiency/Factor V Leiden mutation/aPPL antibody/Prothrombin variant/Homocysteinaemia
Polycythaemia/Thrombocythaemia/PN Haemoglobinuria/Sickle Cell Anaemia
ID - Serious Infection
GE - IBD/Obesity
Renal - Nephrotic Syndrome

Also important to recall:

Virchow's Triad

• Endothelial Injury
• Stasis
• Hypercoagulability

Imagine the tube at rush hour - stuck (stasis) at station, filled with people (hypercoagulability) with their bags and briefcases stuck in the doors (endothelial injury).